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Trial of labor in individuals with twin pregnancies and two prior cesarean deliveries was not associated with significantly increased maternal or neonatal morbidity. OBJECTIVE: To investigate short-term maternal and neonatal outcomes in individuals with twin pregnancies and two prior cesarean deliveries who underwent trial of labor after cesarean (TOLAC). METHODS: A cross-sectional study of live-birth data was conducted between 2014 and 2021 in the United States. Individuals with more than two prior cesarean deliveries and multiple gestations higher than twins were excluded. The inclusion criteria were individuals with twin pregnancies who had two prior cesarean deliveries and underwent TOLAC. Comparison groups included 1) individuals with twin pregnancies and two prior cesarean deliveries who underwent elective cesarean delivery, 2) those with twin pregnancies and one prior cesarean delivery who underwent TOLAC, and 3) those with singleton pregnancies and two prior cesarean deliveries who underwent TOLAC. The primary outcomes were composite measures of maternal and neonatal morbidity. Investigated maternal outcomes included chorioamnionitis, transfusion, hysterectomy, uterine rupture, and admission to the intensive care unit. Vaginal birth after cesarean (VBAC) was also evaluated. Neonatal outcomes included a 5-minute Apgar score 3 or higher, assisted ventilation, admission to the neonatal intensive care unit, use of surfactant or antibiotics, and seizures. Univariable and multivariable analyses were conducted. Bonferroni adjustment was applied, and adjusted P <0.05 was considered significant. RESULTS: A total of 92,665 pregnant individuals and 106,361 neonates were included in the analysis. Vaginal birth after cesarean was achieved in 37.8% (239/632) of individuals with twin pregnancies and two prior cesarean deliveries who underwent TOLAC, compared with 61.5% (2,271/3,693) of individuals with twin pregnancies and one prior cesarean delivery who underwent TOLAC and 58.0% (45,834/78,969) of individuals with singleton pregnancies and two prior cesarean deliveries who underwent TOLAC (P <.001). Both composite maternal and neonatal morbidity were not significantly different between other twin groups and individuals with twin pregnancies and two prior cesarean deliveries who underwent TOLAC. None of the 632 individuals with twin pregnancies and two prior cesarean deliveries who underwent TOLAC had uterine rupture. After adjustments with covariates, the odds of VBAC were more than twice as great in individuals with twin pregnancies and one prior cesarean delivery (adjusted odds ratio [aOR] 2.41; 95% CI, 2.01–2.90) and in those with singleton pregnancies and two prior cesarean deliveries (aOR 2.23; 95% CI, 1.88–2.65) compared with individuals with twin pregnancies and two prior cesarean deliveries. CONCLUSION: No significant difference in adverse maternal or neonatal outcomes were detected in twin pregnancies among individuals with two prior cesarean deliveries, although the chance of VBAC was 37.8%. [ABSTRACT FROM AUTHOR]

The study aimed to develop structured, expert-based clinical guidance on the prenatal and postnatal management of hemolytic disease of the fetus and newborn. A Delphi procedure was conducted among an international panel of experts in fetal medicine, neonatology, and hematology. Experts were selected based on their expertise, relevant publications, and affiliations. The domains were (i) prenatal workup, (ii) prenatal monitoring and management, (iii) intrauterine transfusion (IUT), (iv) delivery, and (v) postnatal management. The predefined cut-off for consensus was ≥70% agreement. One hundred-seven experts representing 25 countries across 6 continents completed the first round, and 100 (93.5%) completed the subsequent rounds. 75.3% agreed on using cfDNA to determine fetal antigen status, particularly for RhD, Kell, and Rhc antigens. The critical titer, requiring fetal monitoring via ultrasound, is considered when the threshold of ≥16 is for non-Kell antigens. 70.0% agreed on the use of maternal IVIg in pregnancies with prior IUT <24 weeks or fetal/neonatal death due to HDFN. The minimum GA for IUT is 16 to 18 weeks, and the maximum is 350/7 to 356/7 weeks. Postnatal management consensus was reached for the following: anemia labs should be investigated in the affected neonates before hospital discharge (92.0% agreement), and if they received IUT, the labs should be repeated within 1 week of discharge (84.0% agreement). 96.0% agreed that exchange transfusions should be centralized in hospitals with sufficient exposure and experience, and 92.0% agreed that the hemoglobin cut-off level to consider transfusion following hospital discharge is 7 g/dL, and the newborns need to be monitored until 2 to 3 months of age (96.0% agreement). [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: Being able to counsel patients with one prior cesarean birth on the risk of uterine rupture with a trial of labor after cesarean, (TOLAC) is an important aspect of prenatal care. Despite uterine rupture being a catastrophic event, there is currently no successful, validated prediction model to predict its occurrence. Material and Methods: This was a cross‐sectional study using US national birth data between 2014 and 2021. The primary objective was to identify risk factors for uterine rupture during TOLAC and to generate a prediction model for uterine rupture among singleton gestations with one prior cesarean as their only prior birth. The secondary objective was to describe the maternal and neonatal morbidity associated with uterine rupture. The association of all candidate variables with uterine rupture was tested with uni‐ and multi‐variable logistic regression analyses. We included term and preterm singleton pregnancies with one prior birth that was cesarean birth (CB) with cephalic presentation undergoing TOLAC. We excluded pregnancies with major structural anomalies and chromosomal abnormalities. The Receiver Operating Characteristics (ROC) Curve was generated. p value <0.001 was considered statistically significant. Results: Of the 270 329 singleton pregnancies with one prior CB undergoing TOLAC during the study period, there were 957 cases of uterine rupture (3.54 cases per 1000). Factors associated with uterine rupture in multivariable models were an interpregnancy interval < 18 months vs the reference interval of 24–35 months (aOR 1.55; 95% CI, 1.19–2.02), induction of labor (aOR 2.31; 95% CI, 2.01–2.65), and augmentation of labor (aOR 1.94; 95% CI, 1.70–2.21). Factors associated with reduced rates of uterine rupture were maternal age < 20 years (aOR 0.33, 95% CI 0.15–0.74) and 20–24 years (aOR 0.79, 95% CI 0.64–0.97) vs the reference of 25–29 years and gestational age at delivery 32–36 weeks vs the reference of 37–41 weeks (aOR 0.55, 95% CI 0.38–0.79). Incorporating these factors into a predictive model for uterine rupture yielded an area under the receiver‐operating curve of 0.66. Additionally, all analyzed maternal and neonatal morbidities were increased in the setting of uterine rupture compared to non‐rupture. Conclusions: Uterine rupture prediction models utilizing TOLAC characteristics have modest performance. [ABSTRACT FROM AUTHOR]

Background: Obesity rates have significantly increased globally, affecting up to 40% of women of childbearing age in the United States. While prenatal repair of open fetal spina bifida has shown improved outcomes, most fetal surgery centers exclude patients with a body mass index (BMI) ≥ 35 kg/m2 based on criteria from the Management of Myelomeningocele Study (MOMS) trial. This exclusion raises concerns about healthcare equity and highlights a significant knowledge gap regarding the safety and efficacy of fetal spina bifida repair in patients with obesity. Objective: To review the current state of knowledge regarding open fetal surgery for fetal spina bifida in patients with obesity, focusing on safety, efficacy, and clinical considerations. Methods: A comprehensive literature search was conducted using the PubMed and EMBASE databases, covering articles from the inception of the databases to April 2024. Studies discussing fetal surgery for neural tube defects and documenting BMI measurements and their impact on surgical outcomes, published in peer-reviewed journals, and available in English were included. Quantitative data were extracted into an Excel sheet, and data synthesis was conducted using the R programming language (version 4.3.3). Results: Three retrospective studies examining outcomes of prenatal open spina bifida repair in a total of 43 patients with a BMI ≥ 35 kg/m2 were identified. These studies did not report significant adverse maternal or fetal outcomes compared to patients with lower BMIs. Our pooled analysis revealed a perinatal mortality rate of 6.1% (95% CI: 1.76–18.92%), with 28.0% (95% CI: 14.0–48.2%) experiencing the premature rupture of membranes and 82.0% (95% CI: 29.2–98.0%) delivering preterm (<37 weeks). Membrane separation was reported in 10.3% of cases (95% CI: 3.3–27.7%), the mean gestational age at birth was 34.3 weeks (95% CI: 32.3–36.3), and the average birth weight was 2651.5 g (95% CI: 2473.7–2829.4). Additionally, 40.1% (95% CI: 23.1–60.0%) required a ventriculoperitoneal shunt. Conclusion: While current evidence suggests that fetal spina bifida repair may be feasible in patients with obesity, significant limitations in the existing body of research were identified. These include small sample sizes, retrospective designs, and a lack of long-term follow-up data. There is an urgent need for large-scale, prospective, multicenter studies to definitively establish the safety and efficacy of fetal spina bifida repair in patients with obesity. Such research is crucial for developing evidence-based guidelines, improving clinical outcomes, and addressing healthcare disparities in this growing patient population with obesity. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the characteristics and outcomes of fetal cardiac rhabdomyoma with or without prenatal use of mammalian target of rapamycin inhibitor (mTORi). Search Strategy: We systematically searched PubMed, Scopus, and Web of Science until June 2023. Selection Criteria: Studies reporting on pregnancies with fetal cardiac rhabdomyoma were included. Data Collection and Analysis: A meta‐analysis of proportions was conducted only on studies that included three or more cases. Results: A systematic review included 61 studies reporting on 400 fetuses with cardiac rhabdomyoma, of which 52 studies (389 fetuses) had expectant management and 9 studies (11 fetuses) were managed with mTORi. The meta‐analysis included 26 studies reporting on 354 fetuses. Prenatally, 14% (95% CI 4–36) had pericardial effusion, 13% (95% CI 6–27) had arrhythmia, 16% (95% CI 7–31) had outflow tract obstruction, and 10% (95% CI 4–21) had hydrops. Fetal demise occurred in 12% (95% CI 5–30). Before delivery, tumor size reduction was noted in 13%, and after birth in 58%. Following birth, 8% (95% CI 3–14) had neonatal death and 9% (95% 4–17) required cardiac surgery. 60% (95% CI 41–79) of cases were diagnosed with tuberous sclerosis. Seizures were reported only in cases with a tuberous sclerosis diagnosis (41/71 infants). For the 9 studies reporting all together on 11 fetuses with tuberous sclerosis receiving prenatal mTORi, they showed improvement in the size of cardiac rhabdomyoma as well as outflow obstruction and none had fetal demise or neonatal death, and none required postnatal cardiac surgery. Conclusions: We report on the natural history of prenatal cardiac rhabdomyoma, including characteristics, progression, and survival. We report 11 fetuses with tuberous sclerosis and cardiac rhabdomyoma receiving prenatal mTORi, showing promising results. [ABSTRACT FROM AUTHOR]

Ebstein anomaly (EA) is a rare congenital cardiac malformation associated with high perinatal mortality. In this systematic review and meta‐analysis, we aimed to investigate the outcomes of pregnancies affected by EA or tricuspid valve dysplasia (TVD) with circular shunt, focusing on two prenatal management approaches: (1) expectant management (EM) and (2) transplacental non‐steroidal anti‐inflammatory drugs (NSAID) therapy. We searched PubMed, Scopus, and Web of Science systematically from its inception until June 2023. The random‐effect model was used to pool the data. Heterogeneity was assessed using the I2 value. Twenty‐one studies with a total of 610 fetuses with EA/TVD with circular shunt were included in the synthesis, of which 17 studies (583 fetuses) were on EM and 4 studies (27 fetuses) used transplacental NSAID therapy. The NSAID group had higher rates of moderate to severe tricuspid regurgitation, hydrops, and pericardial effusion on prenatal ultrasound compared with the EM group. However, ductal constriction was achieved in 81% of NSAID cases, mitigating the disease pathophysiology, although 65% of them experienced oligohydramnios. Notably, the NSAID group showed significantly higher rates of live birth (86%) and survival to hospital discharge (89%) compared with the EM group (67% and 43%, respectively). Despite these promising results, it's important to acknowledge that the number of cases treated with NSAIDs was small, with limited safety data. Therefore, caution is advised in interpreting these findings, and patients considering NSAID therapy should be informed about these limitations. Future multicenter studies are necessary to further explore the safety and effectiveness of NSAID therapy in this particular population. Key points: What's already known about this topic? Ebstein anomaly (EA) and tricuspid valve dysplasia (TVD) are associated with severe tricuspid regurgitation (TR) and pulmonary regurgitation (PR).When PR is present, a circular shunt ensues with ineffective systemic blood flow leading to perinatal mortality.Transplacental administration of non‐steroidal anti‐inflammatory drugs (NSAIDs) may result in a narrowing of the fetal ductus arteriosus (DA) and PR improvement in fetuses with severe EA/TVD. What does this review add? This is the first systematic review and meta‐analysis that comprehensively compares expectant management (EM) versus treatment with NSAIDs in fetal EA/TVD with a circular shunt.Among fetuses with EA/TVD with circular shunt with EM, only 43% survived to hospital discharge versus 89% of those treated with NSAIDs. [ABSTRACT FROM AUTHOR]

To investigate outcomes of fetuses with hypoplastic left heart syndrome (HLHS) with an intact or restrictive atrial septum (I/RAS) managed expectantly or with fetal atrial septal intervention (FASI PubMed, Scopus, and Web of Science were searched systematically from inception until April 2023. Outcomes were classified by those who had FASI and those who had expectant management (EM). To estimate the overall proportion of each endpoint, a meta‐analysis of proportions was employed using a random‐effects model. Heterogeneity was assessed using the I2 value. Thirty‐two studies reporting on 746 fetuses with HLHS and I/RAS met our inclusion criteria. Eleven studies (123 fetuses) were in the FASI group and 21 studies (623 fetuses) were in the EM group. Among the 123 FASI cases, 107 (87%) were reported to be technically successful. The mean gestational age (GA) at diagnosis was comparable between the groups (26.2 weeks FASI vs. 24.4 weeks EM group). The mean GA at FASI was 30.4 weeks (95% CI 28.5, 32.5). The mean GA at delivery was also comparable (37.7 weeks FASI vs. 38.1 weeks EM group). Neonatal outcomes, including live birth, neonatal death, and survival to hospital discharge pooled proportions, were also comparable between groups (live birth: 92% (95% CI 64, 99) FASI versus 93% (95% CI 79, 98) in EM, neonatal death: 32% (95% CI 11, 65) FASI versus 30% (95% CI 21, 41) EM, survival to hospital discharge: 37% (95% CI 25, 52) FASI versus 52% (95% CI 42, 61) EM). Age at neonatal death was higher in the FASI group (mean: 17 days FASI vs. 7.2 days EM group). There was a lower rate of postnatal atrial restrictive septum in the FASI group 38% (95% CI 17, 63) compared to the EM group 88% (95% CI 57, 98). Our review shows variations across centers in the selection criteria and techniques used for FASI. Although survival including livebirth, neonatal death, and survival to hospital discharge did not differ between groups, the procedure may translate into a less restrictive septum at birth. Future multicenter studies are needed to better identify the subset of cases that might have improved outcomes, use standardized definitions, unified techniques, utilize core outcome set, and assess long‐term benefits. Key points: What's already known about this topic? In the setting of hypoplastic left heart syndrome (HLHS), the patency of the inter‐atrial septum is essential to ensure unobstructed drainage of pulmonary venous blood from the left to the right atrium.Prenatal consequences of HLHS with severe atrial restriction include marked elevation in left atrial and pulmonary venous pressures, reduced lung perfusion, and pulmonary lymphangiectasia.Left atrial decompression by the fetal atrial septal intervention (FASI) may offer a means of avoiding or reversing severe pulmonary damage and, thus, a more favorable postnatal outcome. What does this study add? Our review shows variations across centers in their selection criteria and techniques used for fetal atrial septal intervention (FASI) for prenatal hypoplastic left heart syndrome (HLHS) with intact or restrictive atrial septum (I/RAS).There was slightly higher fetal demise in the FASI group.GA at delivery was comparable between FASI and expectant management.Survival outcomes including livebirth, neonatal death, and survival to hospital discharge pooled proportions were also comparable between the two groups.Age at neonatal death was later in the FASI group (mean: 17 days in the FASI vs. 7.5 days in the EM group).47% of FASI cases had postnatal atrial restrictive septum compared to 89% in the expectant group. [ABSTRACT FROM AUTHOR]

Background: Pseudoamniotic band sequence (PABS) is a rare iatrogenic consequence of invasive fetal interventions, most commonly fetoscopic laser surgery (FLS) in monochorionic multiple pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). Objectives: The aim of this study was to investigate prenatal risk factors and perinatal outcomes for pregnancies involving PABS after FLS for TTTS and compare outcomes between those undergoing fetoscopic band release versus not. Method: We conducted a systematic search of PubMed, Scopus, and Web of Science on studies reporting PABS following FLS for TTTS. A meta-analysis of pooled proportions was conducted. Results: There were 16 studies covering 47 pregnancies complicated by PABS following FLS, mostly case series and case reports. The incidence of PABS was 2%, with the recipient twin affected in 94% of the cases. Pregnancies complicated by PABS were associated with inter-twin septostomy in 32% and chorioamniotic separation (CAS) in 90%. The mean gestational age (GA) at FLS and delivery were 17.7 and 30.9 weeks, respectively. Preterm premature rupture of membranes (PPROM) happened in 62% of pregnancies. The risk of preterm birth (PTB) <34 weeks, <32 weeks, and <28 weeks were 94%, 67%, and 31%, respectively. There were 41% fetal demises and 64% live births among the affected fetuses. Results of fetoscopic band release versus not were comparable, including GA at delivery, PPROM, and PTB at 32 weeks. It was noted that the likelihood of PTB by 28 weeks (67% vs. 23%) and fetal death (50% vs. 39%) were higher in the band release group. It was similar between groups in terms of postnatal amputation. Conclusions: PABS causes amputations or fetal death in more than one-third of cases. Pregnancies with an inter-twin septostomy, CAS, advanced TTTS staging, and early GA are more likely to experience PABS. In addition, more than a third of FLS-treated TTTS resulted in PTB and PPROM. PABS cases with prenatal band release showed higher rates of PTB and fetal death, but the data were from small, heterogeneous studies. [ABSTRACT FROM AUTHOR]